How optimistic should we be about progress in global nutrition? Global poverty rates have fallen dramatically over the past 20 years because of rapid economic growth in China, combined with its relatively low initial levels of inequality and its large population. Will we see the same for global stunting rates because of progress in India? Will India be the new China?
Well, the
stunting declines (for under 2s) in the Indian state of Maharashtra between 2006 and 2012 have been dramatic--from about 39% to 23%-- a decline of 16 percentage points. Maharashtra is a relatively well off state with a real commitment to stunting reduction so we might not see that level of reduction nationwide, but even if we saw a 10% decline across all of India that alone would reduce the worldwide number of children that are stunted from 165 million to 150 million. The
WHA targets for 2025 are a 40% decline in the number of stunted under 5 year olds, which is a target of 100 million. So a decline of 10% in stunting rates in India by 2014 (and the NFHS4 national survey is reporting in the next year) will close 20% of this WHA gap in 15% of the time elapsed (2 out of 15 years)--so, well ahead of the global curve, even with only the India data. Of course all-India might not show these declines in 2014 and other parts of the world might not either, but there is sufficient movement in commitment to be optimistic.
With that optimism in mind, and after asking politely why it took so long to follow up on the First International Conference on Nutrition (in 1992), here would be my introductory text (if asked) for the
Second International Conference on Nutrition (ICN2, Rome, November 2014).
Ending Undernutrition: In Clear Sight
For the first time in decades, the
opportunity to end undernutrition is in clear sight. The clarity is driven by a sense of being
closer than ever and also by a much better grasp of what to do, why to do it
and how to do it. Which elements are coming together to create this
transformative opportunity, this perfect storm for undernutrition reduction?
First, we have the know-how. We increasingly recognise that investments in
nutrition pre and post conception are vital if we are to lock in a bright
future for the next generation. Increasingly
we know what the most cost effective interventions are. We recognise that multiple sectors have to
work in harmony to achieve this step change in undernutrition reduction. We realise that income growth is vital to
support the funding of nutrition-related investments and that responsible and
responsive governments are essential for the creation of an enabling
environment where investments in nutrition are encouraged and, in turn, deliver
improvements in nutrition outcomes.
Second, the enabling environment is
promising. Climate change is an ever
present uncertainty, but economic growth in the low and middle income countries
is strong, generating increases in food security, improved water and sanitation
provision, supporting empowerment for women and strengthening health systems. This growth also generates tax revenues which
can be invested in the social sector and to nutrition in particular. Governance is also improving. Government performance is increasingly
recognised as critical for preventing the ravages of conflict; for making it
easier for the private sector to do business and generate good jobs; and for allocating
resources in an equitable way. The
commitment from development partners to nutrition has never been stronger, and
is beginning to translate through into increased investments. And if the High Level Panel’s report is
indicative of a direction of travel, the post-2015 development goals will
feature nutrition more strongly than the MDGs have.
Third, we have examples which inspire
us and which we can learn from. There
have been rapid declines in undernutrition rates in Bangladesh, Cambodia,
Ghana, Peru, Vietnam and the Indian State of Maharashtra. These places are achieving declines in line
with the 2025 goals developed by the World Health Assembly through a
combination of broad based economic growth, more responsive and responsible
governance, and stronger, more strategic nutrition related investments. They have a rationale for investing in
nutrition and credible costed plans for doing so. When these plans start delivering results
they also generate widespread political support, helping to keep their governments
in power and their citizens alive and thriving.
Finally, many low and middle income
countries are experiencing a once in a lifetime demographic transition. For these countries the ratio of people of
working age to those of nonworking age is going to peak in 2040. If these new adults of 2040 can find decent
work, this transition will represent a massive demographic dividend for their
families and for their nations. But this
dividend will only be realised if the brains of those labour force entrants of
2040 were allowed to fully develop as infants 20-25 years earlier, allowing
them to maximise learning in school and to raise their productivity in the
labour force. Flooding the labour force
with young adults who have been undernourished as infants and are therefore
less able to find gainful employment could well represent a demographic
nightmare, one that is characterised by unemployment, unrest and violence.
What needs to be done to deliver the demographic
dividend and ward off the nightmare?
First, we need to build up political
commitment to reduce undernutrition. We
can’t wait for political will to materialise like manna from the skies, we need
to build it from the ground up.
Undernutrition’s manifestations, budgets and accountabilties tend to be
invisible. How can we bring them into
the light? There are many ways of doing
this: using new mobile technologies to monitor nutrition outcomes and programme
coverage in real time; deploying new social accountability tools to empower
citizens to tell us whether they are satisfied with the integrity and quality
of efforts to reduce undernutrition, and taking advantage of rapidly expanding big
databanks to monitor the commitment and actions of governments and others to
reduce undernutrition. Because reducing
undernutrition requires many actors and many actions, it needs a relentless forward
momentum of the kind that can only be powered by strong and enduring political
commitment.
Second, we need to be more creative
about mobilising resources for undernutrition reduction. The additional funding needed to end
undernutrition is not trivial, but it is also defendable. For example, at best, nutrition investments
comprise 4% of overseas development assistance ($5 billion out of $138 billion)
despite undernutrition responsible for 45% of all mortality of children under
5. This is the ODA situation, and it
probably is reflected in domestic resource allocation. Something is wrong with this picture. Perhaps the mismatch occurs because while the
benefits of undernutrition prevention are large – with benefit-cost ratios in
the region of 20-30--the returns take a generation to materialise. Current financial instruments cannot deal
with such long lags—we need innovative new resource mobilisation models
(development impact bonds for example) to help families and countries avoid an
undernutrition trap. But this cannot be a public sector only
responsibility. We also need the private
sector to join the fight, and bring in their own resources and know how, but on
the terms of those who put public health ahead of private gain. The private sector needs its consumer base to
survive and thrive—for commercial as well as humanitarian reasons.
Third, these resources need to be
invested in interventions and policies that have been shown to have an impact
on nutrition. The evidence base needs to
be rigorous but diverse, a mix of demonstrable cause and effect and plausible
pathways of impact. Nutrition specific interventions need to be scaled up. The
arsenal of nutrition sensitive interventions needs to be expanded. The potency
of the enabling environments created to stimulate undernutrition reduction need
to match the more familiar ones created to stimulate general private sector
investment.
Finally, we need to build a new
generation of nutrition leaders—from community health workers to prime
ministers and presidents. They need to
be fearless boundary crossers, not easily captured by a sector. They should be
idealistic pragmatists, not confined by ideology. They must be alliance builders, as at ease
with the political aspects of undernutrition as they are with the technical
details. These leaders are in demand but
are in short supply. Governments and development
partners need to invest in the messy world of capacity development. These leaders are the ones who build
commitment and turn it into the actions that can end undernutrition.
This is the world we are in. We are in the midst of a perfect storm for
nutrition. Perfect because it has the
power to sweep away all the old prejudices and misconceptions about
nutrition. Stormy because it has the
power for transformative change, but also because it might blow itself out
before it can do its good work. Zero
undernutrition is perhaps possible within the next 15 years or so, but it will require
maximum effort from a wide ranging movement of people and ideas. Make no mistake, we are members of a world
citizenry that can actually make undernutrition invisible. Not because it continues to do its silent but
terrifyingly destructive work in the background, but because it will have
become a thing of the past.